Qualitative and quantitative methods

Nursing Research

Methods and Critical Appraisal for Evidence-Based Practice

NINETH EDITION

Geri LoBiondo-Wood, PhD, RN, FAAN
Professor and Coordinator, PhD in Nursing Program, University of Texas Health Science Center at Houston, School of Nursing, Houston, Texas

Judith Haber, PhD, RN, FAAN
The Ursula Springer Leadership Professor in Nursing, New York University, Rory Meyers College of Nursing, New York, New York

Table of Contents

Cover image

Title page

Copyright

About the authors

Contributors

Reviewers

To the faculty

To the student

Acknowledgments
I. Overview of Research and Evidence-Based Practice

Introduction

References

1. Integrating research, evidence-based practice, and quality improvement processes

References

2. Research questions, hypotheses, and clinical questions

References

3. Gathering and appraising the literature

References

4. Theoretical frameworks for research

References

II. Processes and Evidence Related to Qualitative Research

Introduction

References

5. Introduction to qualitative research

References

6. Qualitative approaches to research

References

7. Appraising qualitative research

Critique of a qualitative research study

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References

References

III. Processes and Evidence Related to Quantitative Research

Introduction

References

8. Introduction to quantitative research

References

9. Experimental and quasi-experimental designs

References

10. Nonexperimental designs

References

11. Systematic reviews and clinical practice guidelines

References

12. Sampling

References

13. Legal and ethical issues

References

14. Data collection methods

References

15. Reliability and validity

References

16. Data analysis: Descriptive and inferential statistics

References

17. Understanding research findings

References

18. Appraising quantitative research

Critique of a quantitative research study

Critique of a quantitative research study

References

References

References

IV. Application of Research: Evidence-Based Practice

Introduction

References

19. Strategies and tools for developing an evidence-based practice

References

20. Developing an evidence-based practice

References

21. Quality improvement

References

Example of a randomized clinical trial (Nyamathi et al., 2015) Nursing case management peer coaching and hepatitis A and B vaccine
completion among homeless men recently released on parole

Example of a longitudinal/Cohort study (Hawthorne et al., 2016) Parent spirituality grief and mental health at 1 and 3 months after their
infant schild s death in an intensive care unit

Example of a qualitative study (van dijk et al., 2015) Postoperative patients perspectives on rating pain: A qualitative study

Example of a correlational study (Turner et al., 2016) Psychological functioning post traumatic growth and coping in parents and siblings of
adolescent cancer survivors

Example of a systematic Review/Meta analysis (Al mallah et al., 2015) The impact of nurse led clinics on the mortality and morbidity of
patients with cardiovascular diseases

Glossary

Index

Special features

Copyright

3251 Riverport Lane
St. Louis, Missouri 63043

NURSING RESEARCH: METHODS AND CRITICAL APPRAISAL FOR EVIDENCE-BASED PRACTICE, NINTH EDITION ISBN: 978-0-323-
43131-6

Copyright © 2018 by Elsevier, Inc. All rights reserved.

No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including
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This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted
herein).

N o t i c e s
Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in
research methods, professional practices, or medical treatment may become necessary.

Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information,
methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety
and the safety of others, including parties for whom they have a professional responsibility.

With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on
procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method
and duration of administration, and contraindications. It is the responsibility of practitioners, relying on their own experience and
knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all
appropriate safety precautions.

To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors assume any liability for any injury and/or
damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods,
products, instructions, or ideas contained in the material herein.

Previous editions copyrighted 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986.

Library of Congress Cataloging-in-Publication Data

Names: LoBiondo-Wood, Geri, editor. | Haber, Judith, editor.
Title: Nursing research : methods and critical appraisal for evidence-based
 practice / [edited by] Geri LoBiondo-Wood, Judith Haber.
Other titles: Nursing research (LoBiondo-Wood)
Description: 9th edition. | St. Louis, Missouri : Elsevier, [2018] | Includes
 bibliographical references and index.
Identifiers: LCCN 2017008727 | ISBN 9780323431316 (pbk. : alk. paper)
Subjects: | MESH: Nursing Research—methods | Research Design |
 Evidence-Based Nursing—methods
Classification: LCC RT81.5 | NLM WY 20.5 | DDC 610.73072—dc23 LC record available
at https://lccn.loc.gov/2017008727

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About the authors

Geri LoBiondo-Wood, PhD, RN, FAAN, is Professor and Coordinator of the PhD in Nursing Program at the University of Texas Health
Science Center at Houston, School of Nursing (UTHSC-Houston) and former Director of Research and Evidence-Based Practice Planning and
Development at the MD Anderson Cancer Center, Houston, Texas. She received her Diploma in Nursing at St. Mary’s Hospital School of
Nursing in Rochester, New York; Bachelor’s and Master’s degrees from the University of Rochester; and a PhD in Nursing Theory and
Research from New York University. Dr. LoBiondo-Wood teaches research and evidence-based practice principles to undergraduate,
graduate, and doctoral students. At MD Anderson Cancer Center, she developed and implemented the Evidence-Based Resource Unit Nurse
(EB-RUN) Program. She has extensive national and international experience guiding nurses and other health care professionals in the
development and utilization of research. Dr. LoBiondo-Wood is an Editorial Board member of Progress in Transplantation and a reviewer for
Nursing Research, Oncology Nursing Forum, and Oncology Nursing. Her research and publications focus on chronic illness and oncology
nursing. Dr. Wood has received funding from the Robert Wood Johnson Foundation Future of Nursing Scholars program for the past several
years to fund full-time doctoral students.

Dr. LoBiondo-Wood has been active locally and nationally in many professional organizations, including the Oncology Nursing Society,
Southern Nursing Research Society, the Midwest Nursing Research Society, and the North American Transplant Coordinators Organization.
She has received local and national awards for teaching and contributions to nursing. In 1997, she received the Distinguished Alumnus
Award from New York University, Division of Nursing Alumni Association. In 2001 she was inducted as a Fellow of the American Academy
of Nursing and in 2007 as a Fellow of the University of Texas Academy of Health Science Education. In 2012 she was appointed as a
Distinguished Teaching Professor of the University of Texas System and in 2015 received the John McGovern Outstanding Teacher Award
from the University of Texas Health Science Center at Houston School of Nursing.

Judith Haber, PhD, RN, FAAN, is the Ursula Springer Leadership Professor in Nursing at the Rory Meyers College of Nursing at New York
University. She received her undergraduate nursing education at Adelphi University in New York, and she holds a Master’s degree in Adult
Psychiatric–Mental Health Nursing and a PhD in Nursing Theory and Research from New York University. Dr. Haber is internationally
recognized as a clinician and educator in psychiatric–mental health nursing. She was the editor of the award-winning classic textbook,
Comprehensive Psychiatric Nursing, published for eight editions and translated into five languages. She has extensive clinical experience in
psychiatric nursing, having been an advanced practice psychiatric nurse in private practice for over 30 years, specializing in treatment of
families coping with the psychosocial impact of acute and chronic illness. Her NIH-funded program of research addressed physical and
psychosocial adjustment to illness, focusing specifically on women with breast cancer and their partners and, more recently, breast cancer
survivorship and lymphedema prevention and risk reduction. Dr. Haber is also committed to an interprofessional program of clinical
scholarship related to interprofessional education and improving oral-systemic health outcomes and is the Executive Director of a national
nursing oral health initiative, the Oral Health Nursing Education and Practice (OHNEP) program, funded by the DentaQuest and Washington
Dental Service Foundations.

Dr. Haber is the recipient of numerous awards, including the 1995 and 2005 APNA Psychiatric Nurse of the Year Award, the 2005 APNA
Outstanding Research Award, and the 1998 ANA Hildegarde Peplau Award. She received the 2007 NYU Distinguished Alumnae Award,
the 2011 Distinguished Teaching Award, and the 2014 NYU Meritorious Service Award. In 2015, Dr. Haber received the Sigma Theta Tau
International Marie Hippensteel Lingeman Award for Excellence in Nursing Practice. Dr. Haber is a Fellow in the American Academy of
Nursing and the New York Academy of Medicine. Dr. Haber has consulted, presented, and published widely on evidence-based practice,
interprofessional education and practice, as well as oral-systemic health issues.

Contributors

Terri Armstrong, PhD, ANP-BC, FAANP, Senior Investigator, Neuro-oncology Branch, Center for Cancer Research, National Cancer
Institute, National Institutes of Health, Bethesda, Maryland

Julie Barroso, PhD, ANP, RN, FAAN, Professor and Department Chair, Medical University of South Carolina, Charleston, South
Carolina

Carol Bova, PhD, RN, ANP, Professor of Nursing and Medicine, Graduate School of Nursing, University of Massachusetts, Worcester,
Massachusetts

Dona Rinaldi Carpenter, EdD, RN, Professor and Chair, University of Scranton, Department of Nursing, Scranton, Pennsylvania

Maja Djukic, PhD, RN, Assistant Professor, Rory Meyers College of Nursing, New York University, New York, New York

Mei R. Fu, PhD, RN, FAAN, Associate Professor, Rory Meyers College of Nursing, New York University, New York, New York

Mattia J. Gilmartin, PhD, RN, Senior Research Scientist , Executive Director, NICHE Program, Rory Meyers College of Nursing, New
York University, New York, New York

Deborah J. Jones, PhD, MS, RN, Margaret A. Barnett/PARTNERS Professorship , Associate Dean for Professional Development and
Faculty Affairs , Associate Professor, University of Texas Health Science Center at Houston, School of Nursing, Houston, Texas

Carl Kirton, DNP, RN, MBA, Chief Nursing Officer, University Hospital, Newark, New Jersey; , Adjunct Faculty, Rory Meyers College
of Nursing, New York University, New York, New York

Barbara Krainovich-Miller, EdD, RN, PMHCNS-BC, ANEF, FAAN, Professor, Rory Meyers College of Nursing, New York University,
New York, New York

Elaine Larson, PhD, RN, FAAN, CIC, Anna C. Maxwell Professor of Nursing Research , Associate Dean for Research, Columbia
University School of Nursing, New York, New York

Melanie McEwen, PhD, RN, CNE, ANEF, Professor, University of Texas Health Science Center at Houston, School of Nursing, Houston,
Texas

Gail D’Eramo Melkus, EdD, ANP, FAAN, Florence & William Downs Professor in Nursing Research, Associate Dean for Research, Rory
Meyers College of Nursing, New York University, New York, New York

Susan Sullivan-Bolyai, DNSc, CNS, RN, FAAN, Associate Professor, Rory Meyers College of Nursing, New York University, New York,
New York

Marita Titler, PhD, RN, FAAN, Rhetaugh G. Dumas Endowed Professor , Department Chair, Department of Systems, Populations and
Leadership, University of Michigan School of Nursing, Ann Arbor, Michigan

Mark Toles, PhD, RN, Assistant Professor, University of North Carolina at Chapel Hill, School of Nursing, Chapel Hill, North Carolina

Reviewers
Karen E. Alexander, PhD, RN, CNOR, Program Director RN-BSN, Assistant Professor, Department of Nursing, University of Houston
Clear Lake-Pearland, Houston, Texas

Donelle M. Barnes, PhD, RN, CNE, Associate Professor, College of Nursing, University of Texas, Arlington, Arlington, Texas

Susan M. Bezek, PhD, RN, ACNP, CNE, Assistant Professor, Division of Nursing, Keuka College, Keuka Park, New York

Rose M. Kutlenios, PhD, MSN, MN, BSN, ANCC Board Certification, Adult Psychiatric/Mental Health Clinical Specialist, ANCC
Board Certification, Adult Nurse Practitioner, Nursing Program Director and Associate Professor, Department of Nursing, West Liberty
University, West Liberty, West Virginia

Shirley M. Newberry, PhD, RN, PHN, Professor, Department of Nursing, Winona State University, Winona, Minnesota

Sheryl Scott, DNP, RN, CNE, Assistant Professor and Chair, School of Nursing, Wisconsin Lutheran College, Milwaukee, Wisconsin

To the faculty
Geri LoBiondo-Wood, [email protected], Judith Haber, [email protected]

The foundation of the ninth edition of Nursing Research: Methods and Critical Appraisal for Evidence-Based Practice continues to be the belief that
nursing research is integral to all levels of nursing education and practice. Over the past three decades since the first edition of this textbook,
we have seen the depth and breadth of nursing research grow, with more nurses conducting research and using research evidence to shape
clinical practice, education, administration, and health policy.

The National Academy of Medicine has challenged all health professionals to provide team-based care based on the best available
scientific evidence. This is an exciting challenge. Nurses, as clinicians and interprofessional team members, are using the best available
evidence, combined with their clinical judgment and patient preferences, to influence the nature and direction of health care delivery and
document outcomes related to the quality and cost-effectiveness of patient care. As nurses continue to develop a unique body of nursing
knowledge through research, decisions about clinical nursing practice will be increasingly evidence based.

As editors, we believe that all nurses need not only to understand the research process but also to know how to critically read, evaluate,
and apply research findings in practice. We realize that understanding research, as a component of evidence-based practice and quality
improvement practices, is a challenge for every student, but we believe that the challenge can be accomplished in a stimulating, lively, and
learner-friendly manner.

Consistent with this perspective is an ongoing commitment to advancing implementation of evidence-based practice. Understanding and
applying research must be an integral dimension of baccalaureate education, evident not only in the undergraduate nursing research course
but also threaded throughout the curriculum. The research role of baccalaureate graduates calls for evidence-based practice and quality
improvement competencies; central to this are critical appraisal skills—that is, nurses should be competent research consumers.

Preparing students for this role involves developing their critical thinking skills, thereby enhancing their understanding of the research
process, their appreciation of the role of the critiquer, and their ability to actually critically appraise research. An undergraduate research
course should develop this basic level of competence, an essential requirement if students are to engage in evidence-informed clinical
decision making and practice, as well as quality improvement activities.

The primary audience for this textbook remains undergraduate students who are learning the steps of the research process, as well as how
to develop clinical questions, critically appraise published research literature, and use research findings to inform evidence-based clinical
practice and quality improvement initiatives. This book is also a valuable resource for students at the master’s, DNP, and PhD levels who
want a concise review of the basic steps of the research process, the critical appraisal process, and the principles and tools for evidence-based
practice and quality improvement.

This text is also an important resource for practicing nurses who strive to use research evidence as the basis for clinical decision making
and development of evidence-based policies, protocols, and standards or who collaborate with nurse-scientists in conducting clinical
research and evidence-based practice. Finally, this text is an important resource for considering how evidence-based practice, quality
improvement, and interprofessional collaboration are essential competencies for students and clinicians practicing in a transformed health
care system, where nurses and their interprofessional team members are accountable for the quality and cost-effectiveness of care provided
to their patient population. Building on the success of the eighth edition, we reaffirm our commitment to introducing evidence-based
practice, quality improvement processes, and research principles to baccalaureate students, thereby providing a cutting-edge, research
consumer foundation for their clinical practice. Nursing Research: Methods and Critical Appraisal for Evidence-Based Practice prepares nursing
students and practicing nurses to become knowledgeable nursing research consumers by doing the following:

• Addressing the essential evidence-based practice and quality improvement role of the nurse, thereby embedding evidence-based
competencies in clinical practice.

• Demystifying research, which is sometimes viewed as a complex process.

• Using a user-friendly, evidence-based approach to teaching the fundamentals of the research process.

• Including an exciting chapter on the role of theory in research and evidence-based practice.

• Providing a robust chapter on systematic reviews and clinical guidelines.

• Offering two innovative chapters on current strategies and tools for developing an evidence-based practice.

• Concluding with an exciting chapter on quality improvement and its application to practice.

• Teaching the critical appraisal process in a user-friendly progression.

• Promoting a lively spirit of inquiry that develops critical thinking and critical reading skills, facilitating mastery of the critical appraisal
process.

• Developing information literacy, searching, and evidence-based practice competencies that prepare students and nurses to effectively
locate and evaluate the best research evidence.

• Emphasizing the role of evidence-based practice and quality improvement initiatives as the basis for informing clinical decisions that
support nursing practice.

• Presenting numerous examples of recently published research studies that illustrate and highlight research concepts in a manner that

brings abstract ideas to life for students. These examples are critical links that reinforce evidence-based concepts and the critiquing
process.

• Presenting five published articles, including a meta-analysis, in the Appendices, the highlights of which are woven throughout the text as
exemplars of research and evidence-based practice.

• Showcasing, in four new inspirational Research Vignettes, the work of renowned nurse researchers whose careers exemplify the links
among research, education, and practice.

• Introducing new pedagogical interprofessional education chapter features, IPE Highlights and IPE Critical Thinking Challenges and quality
improvement, QSEN Evidence-Based Practice Tips.

• Integrating stimulating pedagogical chapter features that reinforce learning, including Learning Outcomes, Key Terms, Key Points,
Critical Thinking Challenges, Helpful Hints, Evidence-Based Practice Tips, Critical Thinking Decision Paths, and numerous tables,
boxes, and figures.

• Featuring a revised section titled Appraising the Evidence, accompanied by an updated Critiquing Criteria box in each chapter that
presents a step of the research process.

• Offering a student Evolve site with interactive review questions that provide chapter-by-chapter review in a format consistent with that of
the NCLEX® Examination.

• Offering a Student Study Guide that promotes active learning and assimilation of nursing research content.

• Presenting Faculty Evolve Resources that include a test bank, TEACH lesson plans, PowerPoint slides with integrated audience response
system questions, and an image collection. Evolve resources for both students and faculty also include a research article library with
appraisal exercises for additional practice in reviewing and critiquing, as well as content updates.

The ninth edition of Nursing Research: Methods and Critical Appraisal for Evidence-Based Practice is organized into four parts. Each part is
preceded by an introductory section and opens with an engaging Research Vignette by a renowned nurse researcher.

Part I, Overview of Research and Evidence-Based Practice, contains four chapters: Chapter 1, “Integrating Research, Evidence-Based
Practice, and Quality Improvement Processes,” provides an excellent overview of research and evidence-based practice processes that shape
clinical practice. The chapter speaks directly to students and highlights critical reading concepts and strategies, facilitating student
understanding of the research process and its relationship to the critical appraisal process. The chapter introduces a model evidence
hierarchy that is used throughout the text. The style and content of this chapter are designed to make subsequent chapters user friendly. The
next two chapters address foundational components of the research process. Chapter 2, “Research Questions, Hypotheses, and Clinical
Questions,” focuses on how research questions and hypotheses are derived, operationalized, and critically appraised. Students are also
taught how to develop clinical questions that are used to guide evidence-based inquiry, including quality improvement projects. Chapter 3,
“Gathering and Appraising the Literature,” showcases cutting-edge information literacy content and provides students and nurses with the
tools necessary to effectively search, retrieve, manage, and evaluate research studies and their findings. Chapter 4, “Theoretical Frameworks
for Research,” is a user-friendly theory chapter that provides students with an understanding of how theories provide the foundation of
research studies and evidence-based practice projects.

Part II, Processes and Evidence Related to Qualitative Research, contains three interrelated qualitative research chapters. Chapter 5,
“Introduction to Qualitative Research,” provides an exciting framework for understanding qualitative research and the significant
contribution of qualitative research to evidence-based practice. Chapter 6, “Qualitative Approaches to Research,” presents, illustrates, and
showcases major qualitative methods using examples from the literature as exemplars. This chapter highlights the questions most
appropriately answered using qualitative methods. Chapter 7, “Appraising Qualitative Research,” synthesizes essential components of and
criteria for critiquing qualitative research reports using published qualitative research study.

Part III, Processes and Evidence Related to Quantitative Research, contains Chapters 8 to 18Chapter 8Chapter 9Chapter 10Chapter
11Chapter 12Chapter 13Chapter 14Chapter 15Chapter 16Chapter 17Chapter 18. This group of chapters delineates essential steps of the
quantitative research process, with published clinical research studies used to illustrate each step. These chapters are streamlined to make
the case for linking an evidence-based approach with essential steps of the research process. Students are taught how to critically appraise
the strengths and weaknesses of each step of the research process in a synthesized critique of a study. The steps of the quantitative research
process, evidence-based concepts, and critical appraisal criteria are synthesized in Chapter 18 using two published research studies,
providing a model for appraising strengths and weaknesses of studies, and determining applicability to practice. Chapter 11, a unique
chapter, addresses the use of the types of systematic reviews that support an evidence-based practice as well as the development and
application of clinical guidelines.

Part IV, Application of Research: Evidence-Based Practice, contains three chapters that showcase evidence-based practice models and
tools. Chapter 19, “Strategies and Tools for Developing an Evidence-Based Practice,” is a revised, vibrant, user-friendly, evidence-based
toolkit with exemplars that capture the essence of high-quality, evidence-informed nursing care. It “walks” students and practicing nurses
through clinical scenarios and challenges them to consider the relevant evidence-based practice “tools” to develop and answer questions that
emerge from clinical situations. Chapter 20, “Developing an Evidence-Based Practice,” offers a dynamic presentation of important evidence-
based practice models that promote evidence-based decision making. Chapter 21, “Quality Improvement,” is an innovative, engaging
chapter that outlines the quality improvement process with information from current guidelines. Together, these chapters provide an
inspirational conclusion to a text that we hope motivates students and practicing nurses to advance their evidence-based practice and quality
improvement knowledge base and clinical competence, positioning them to make important contributions to improving health care
outcomes as essential members of interprofessional teams.

Stimulating critical thinking is a core value of this text. Innovative chapter features such as Critical Thinking Decision Paths, Evidence-
Based Practice Tips, Helpful Hints, Critical Thinking Challenges, IPE Highlights, and QSEN Evidence-Based Practice Tips enhance
critical thinking, promote the development of evidence-based decision-making skills, and cultivate a positive value about the importance of
collaboration in promoting evidence-based, high quality and cost-effective clinical outcomes.

Consistent with previous editions, we promote critical thinking by including sections called “Appraising the Evidence,” which describe
the critical appraisal process related to the focus of the chapter. Critiquing Criteria are included in this section to stimulate a systematic and

evaluative approach to reading and understanding qualitative and quantitative research and evaluating its strengths and weaknesses.
Extensive resources are provided on the Evolve site that can be used to develop critical thinking and evidence-based competencies.

The development and refinement of an evidence-based foundation for clinical nursing practice is an essential priority for the future of
professional nursing practice. The ninth edition of Nursing Research: Methods and Critical Appraisal for Evidence-Based Practice will help
students develop a basic level of competence in understanding the steps of the research process that will enable them to critically analyze
research studies, judge their merit, and judiciously apply evidence in clinical practice. To the extent that this goal is accomplished, the next
generation of nursing professionals will have a cadre of clinicians who inform their practice using theory, research evidence, and clinical
judgment, as they strive to …

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